SUGGESTED CITATION:
Centers for Disease Control. Prevention and control of tuberculosis
in U.S. communities with at-risk minority populations:
recommendations of the Advisory Council for the Elimination of
Tuberculosis and Prevention and control of tuberculosis among
homeless persons: recommendations of the Advisory Council for the
Elimination of Tuberculosis. MMWR 1992;41(RR-5):(inclusive page
numbers).

CIO RESPONSIBLE FOR THIS PUBLICATION:
National Center for Prevention Services

Summary

Because tuberculosis (TB) is a major problem among homeless
persons, the Advisory Council for the Elimination of Tuberculosis
has developed recommendations to assist health-care providers,
health departments, shelter operators and workers, social service
agencies, and homeless persons prevent and control TB in this
population. TB should be suspected in any homeless person with a
fever and a productive cough of more than 1-3 weeks' duration, and
appropriate diagnostic studies should be undertaken. Confirmed or
suspected TB in a homeless person should be immediately reported to
the health department so that a treatment plan can be decided upon
and potentially exposed persons located and examined. Patients with
TB should be counseled and voluntarily tested for human
immunodeficiency virus (HIV) infection because TB treatment
recommendations are different for HIV-seropositive and
HIV-seronegative persons (1). TB therapy should be directly
observed whenever possible. This may require the establishment of
special shelters or other long-term-care arrangements for homeless
persons with TB. For each person with an infectious case, an
investigation should be conducted to identify exposed persons, and
those found to be infected should be considered for preventive
therapy. Shelter staff should receive a tuberculin skin test when
they start work and every 6-12 months thereafter. Those with
positive skin test results should be considered for preventive
therapy according to current guidelines. Shelters for the homeless
should be adequately ventilated. The installation of ultraviolet
lamps also may be useful to further reduce the risk of TB
transmission.

INTRODUCTION

Since the early 1900s (2), tuberculosis (TB) has been
recognized as an important health problem among homeless persons
and among residents of inexpensive lodging houses, night shelters,
single-room occupancy hotels, and common hostels. Subsequent
reports have continued to call attention to this problem,
especially in the United Kingdom (3-11). With the increase in
homelessness in the United States during the 1980s, TB among
homeless persons became a subject of heightened interest and
concern (12-24).

There is no universally agreed-upon definition of
homelessness; in general, however, the homeless can be defined as
persons who do not have customary and regular access to a
conventional dwelling or residence (25). The exact number of
homeless persons at any given time is not known, and reported
estimates have varied widely. According to the Urban Institute,
there may have been more than 1 million persons in the United
States who were homeless at some time during 1987 (26).

From a national perspective, the overall incidence of active
TB and the prevalence of latent tuberculous infection among the
homeless are unknown. Based on screening at selected clinics and
shelters, the prevalence of clinically active disease ranges from
1.6% to 6.8% and the prevalence of latent TB infection ranges from
18% to 51% (12,13,15-17). Clinical data from the National Health
Care for the Homeless project indicated a point prevalence of
active TB of 968/100,000 homeless adults (27). However, because of
the selective nature of these screening activities, it is not
appropriate to extrapolate these reported prevalence rates
nationwide or to ``special populations,'' such as single-parent
families or runaway children (28).

Although shelters and other inexpensive housing for the
homeless are vital to the survival of these persons, there is
substantial potential for TB transmission in such facilities (18),
especially in the winter when shelters are likely to be more
crowded and ventilation from the outside may be diminished.

The recommendations in this document are intended for the
entire medical community and the public, but are particularly
targeted to health department TB-control programs and to those who
provide health care and other services to homeless persons. Health
departments and shelter operators are encouraged to implement these
recommendations whenever applicable.

ASSESSMENT OF THE MAGNITUDE OF THE PROBLEM

Communities should assess the nature and magnitude of the TB
problem in their area, specifically, the incidence and prevalence
of TB among persons who are homeless. All patients with TB should
be specifically asked whether they are homeless or live at a
single-room occupancy hotel, shelter, or lodging house since they
may not volunteer such information. Health departments should
maintain, and regularly update, listings of single-room occupancy
hotels and homeless shelters so that patients' addresses can be
checked against these listings. Shelters should be encouraged to
maintain lists of names of persons staying there. This will
facilitate health department searches for patients in need of
diagnostic or therapeutic services.

PRIORITIES FOR TB SERVICES

Priorities for TB prevention and control activities among
homeless persons have been established on the basis of their
clinical and public health importance and their cost-effectiveness
(see box).

Priorities for Tuberculosis Prevention and Control Activities
Among Homeless Persons

The highest priority should be given to a) detection,

evaluation, and reporting of homeless persons who have current
symptoms of active TB and b) completion of an appropriate course
of treatment by those diagnosed with active TB.

2. The second priority should be screening and preventive therapy
for homeless persons who have, or are suspected of having, human
immunodeficiency virus ( HIV) infection.

3. The third priority should be the examination and appropriate
treatment of persons with recent TB that has been inadequately
treated.

4. The fourth priority should be screening and appropriate
treatment of persons exposed to an infectious (sputum-positive)
case of TB. Because contacts are difficult to define in a shelter
population, it is usually necessary to screen all residents of a
shelter when an infectious case is identified.

5. The fifth priority should be screening and preventive therapy
for homeless persons with known medical conditions that increase
the risk of TB, e.g., diabetes mellitus (29).

CASE FINDING

Educational materials on TB should be developed for shelter
clients, shelter employees, and volunteers. This material should
address the mode of spread, the common signs and symptoms, and
methods for treatment and prevention. Information on local
resources for TB care should be made available to shelter staff and
guests.

TB case finding should be part of the regular health care
provided to homeless persons. Shelter staff and others providing
services can assist in case finding by identifying persons with a
persistent cough and ensuring that suspected cases are quickly
evaluated by a health-care provider. If this evaluation cannot be
done at the shelter, immediate transportation to a health-care
facility should be provided.

If the clinical evaluation of a symptomatic person is
consistent with TB, appropriate diagnostic tests (e.g., sputum
smears and cultures and chest radiographs) should be done as
quickly as possible. A homeless patient will usually need to be
hospitalized at least until the diagnostic evaluation is complete
and effective therapy instituted.

Routine tuberculin skin test screening of asymptomatic
homeless persons for TB is not an efficient way to find new cases.
Chest radiographic screening of homeless persons may be useful
during outbreak investigations.

CASE REPORTING

The diagnosis of TB in a homeless patient may occur during
diagnosis and treatment of an unrelated problem or during
incarceration in a jail or prison. When a homeless person is
suspected of or diagnosed as having TB, the health department
should be notified promptly so that appropriate follow-up can be
arranged. Delay or failure to notify the health department of a
case of confirmed or suspected TB may result in the patient's being
lost to follow-up, a failure to initiate appropriate treatment, and
continuing transmission of tuberculosis in the community.

CASE MANAGEMENT

Homeless patients with newly diagnosed infectious TB should
be appropriately housed to allow initial therapy to be fully
supervised and to preclude continuing transmission of TB in the
community. Ideally, homeless persons with active TB should be
housed in a special shelter, halfway house, or other long-term
treatment facility until therapy is complete or more permanent
housing is identified. It is also important that ancillary
services, such as substance abuse treatment and evaluation and
treatment of HIV disease, be offered in these facilities.

A health department staff member should visit a homeless
person with suspected or confirmed TB, in the hospital or
elsewhere, as soon as possible after the diagnosis is suspected or
made. The health department worker should make an assessment of the
likelihood of adherence to therapy, if treatment is to be given on
an outpatient basis. During the initial visit, the treatment plan
should be discussed and the patient's cooperation elicited.

Arrangements for the patient's first visit to the clinic or
other place of intended outpatient care should be made before the
patient is discharged from the hospital. Details about personal
activities, friends, and favorite gathering places, which may
assist in locating the patient in the field, should be included in
the chart. A physical description of the patient should also be
included in the chart to assist field workers in locating the
person. It is essential that rapport between the patient and the
health department staff be established and maintained.

The homeless person with TB may not view TB as the highest
priority concern. Other concerns -- e.g., shelter, food, and
safety -- are likely to be of greater priority. Thus, the
involvement of social workers on the treatment team to assist in
solving these other problems is important for achieving successful
treatment of TB.

Treatment must be carefully monitored. Failure of patients to
take TB medications as prescribed can result in relapses, drug
resistance, further transmission of TB, and death. For most
patients, it is desirable that a health-care worker or other
responsible adult directly observe ingestion of medication. This
allows careful monitoring for adherence to therapy and drug side
effects. In addition, carrying medications may be dangerous for
homeless persons; if others believe the medications are addictive
or valuable, the homeless person may be robbed or assaulted.

Whenever possible, TB clinics should be located close to
shelters or other places (e.g., soup kitchens) where homeless
persons receive services. If this is not possible, transportation
to the clinics should be provided. The clinic schedule should
include hours that facilitate patient attendance. Incentives and
enablers to encourage adherence should be used (20-22,30). These
might include items such as food or food vouchers, cash, special
lodging, transportation vouchers or tokens, articles of clothing,
priority in food lines, and assistance in filing for benefits. In
many communities, successful programs represent a cooperative
community activity in which local merchants or American Lung
Association affiliates provide the incentives.

Treatment outcomes are likely to be optimal if homeless
patients have a reliable source of food and shelter throughout the
course of therapy. Some communities have successfully used halfway
houses and special shelters for this purpose. In areas lacking
these alternatives, a longer period of hospitalization in an
acute-care facility may be necessary. Long-term
institutionalization may be essential for the management of
mentally ill or seriously uncooperative patients. If, despite the
efforts of health-care providers, any infectious patient
(regardless of residential status) refuses treatment, temporary
enforced isolation should be instituted in accordance with state
and local public health laws and regulations. This option should be
used when necessary after due legal process. Medicaid reimbursement
for these services should be available in all states.

TREATMENT

A responsible person (e.g., physician, nurse, outreach worker)
should observe the patient ingest medications to prevent treatment
failure, the emergence of drug-resistant organisms, and continued
transmission of infection (31). Provided there is adequate medical
supervision, treatment can be given and observed by designated
persons at the shelter or other location. All TB treatments of
homeless persons should be free of charge to the patient.

Treatment should stress the use of intensive multidrug,
bactericidal regimens for all eligible patients (29). Outpatient
treatment should be a regimen that includes isoniazid and rifampin
in addition to pyrazinamide and ethambutol for the first 2 months
of therapy. Drug susceptibility tests should be initially obtained
on positive cultures from all patients. If the organisms are
susceptible to both isoniazid and rifampin, ethambutol can be
discontinued and the second phase of therapy completed with an
additional 4 months (if patient is HIV negative) or 7 months (if
patient is HIV positive) of treatment with isoniazid and rifampin.
Treatment can be given daily for the first 2 weeks to 2 months and
either daily or twice weekly thereafter, or it can be given three
times weekly from the beginning (32). Baseline laboratory tests
should be done to detect conditions contraindicating certain drugs
and to better assess any subsequent adverse drug reactions (29).

For patients with active pulmonary TB, sputum smears and
cultures should be obtained at 2- to 4-week intervals until
cultures become negative. Patients should be monitored for possible
adverse drug effects by asking them about signs and symptoms.
Appropriate laboratory studies should be obtained when indicated.
Hospitalized patients who are initially found to have positive
sputum smears or cultures can return to the shelter when there is
bacteriologic and clinical evidence of a response to therapy, i.e.,
three consecutive daily negative sputum smears and asymptomatic
status.

PREVENTION

Early case finding and effective treatment of persons with
active TB are the most important measures for preventing spread of
TB in the community. A thorough contact investigation should be
done around every case (33). Although such investigations are
difficult in shelters because of the transient nature of the
population, they should always be attempted.

Contact investigations are usually based upon screening with
the tuberculin skin test, followed by chest radiographs for those
with skin test reactions greater than or equal to 5 mm. Because of
the high prevalence of TB among some homeless populations and
because of the possibility of false-negative tuberculin skin test
reactions due to disease or other factors, it may be useful to
screen homeless populations with chest radiographs during an
outbreak investigation.

Several factors in the shelter environment influence the
likelihood of TB transmission. The absolute number and population
density of persons sharing the same breathing space is an important
transmission factor in shelters. If all other factors are constant,
the size of the shelter population is directly proportional to the
likelihood that someone with infectious TB will be present and that
someone else will become infected (34). Conversely, the smaller and
less crowded the shelter, the lower the risk.

The probability of transmission is affected by building
ventilation. Ventilation should be at or above 25 cubic feet of
outside air per minute per person. Recirculated air may contribute
to transmission within a shelter. During periods of peak occupancy,
it may be difficult to provide ventilation at adequate levels. Air
quality consultants can determine the adequacy of ventilation and
recommend improvements where necessary.

Because even optimal ventilation does not preclude TB
transmission, supplemental upper room germicidal ultraviolet (UV)
air disinfection may be useful to further reduce the chance of
transmission (35). UV lamps may be useful when ongoing transmission
of infection is demonstrated by the continuing occurrence of cases
or skin test conversions. For safety and efficacy reasons, UV
fixtures should be planned, installed, and monitored after
installation by an experienced consultant. To avoid acute eye and
skin injury, shelter staff and workers should be advised not to
look at the tubes in UV fixtures, and exposure at eye level must be
no greater than 0.2 microwatts per square centimeter over 8 hours.
Nonreflective paint should be used in rooms where UV lamps are
located.

Tuberculin skin test screening and isoniazid preventive
therapy programs among homeless persons have been generally
unproductive because of poor patient adherence to follow-up visits
and treatment regimens (36). Screening should be undertaken only if
there is a reasonable possibility that most infected persons
identified will complete preventive treatment. Priorities for
preventive therapy among TB-infected persons have been established
(see box) (29).

Incentives may also be used to improve adherence to preventive
treatment. Twice-weekly directly observed isoniazid preventive
therapy, given in a dose of 15 mg/kg, should be considered if the
person cannot or will not comply with daily self-administered
therapy. Although the efficacy of this regimen has not been proven
in preventive therapy trials, extrapolation from clinical therapy
trials suggests it would be effective (37).

Staff and regular volunteers in shelters for the homeless
should receive a Mantoux tuberculin skin test when they start work
and every 6 to 12 months thereafter. The two-step method of testing
is generally recommended (38). Persons with positive reactions
should be evaluated and considered for preventive therapy according
to current American Thoracic Society / CDC guidelines (29). The
results of staff and volunteer skin tests should be maintained in
a central confidential file.

Clinical data on homeless clients (guests) should be
maintained and shared between shelters.

HIV INFECTION AND TB

HIV infection is a major risk factor for the development of TB
(39). An association between TB, HIV infection, and homelessness
has been documented (21,22,24).

Persons with TB and HIV infection appear to respond to
standard anti-TB drugs (40-42), but data on clinical and
bacteriologic response among these patients are limited. When HIV
infection is known or suspected, the recommended initial treatment
regimen is the same as for non-HIV-infected persons. Patients
treated with rifampin who are on methadone should have the
methadone dosage increased to avoid withdrawal symptoms resulting
from the interaction between the two drugs (43).

If the patient has drug-susceptible organisms, the
continuation phase need include only isoniazid and rifampin. If
resistance to any of the drugs in the regimen is found, the
treatment regimen should be appropriately revised in consultation
with a specialist. Treatment should be continued for a minimum of
9 months and for at least 6 months beyond documented culture
conversion as evidenced by three negative cultures. If either
isoniazid or rifampin is not or cannot be included in the regimen,
therapy should continue at least 18 months and for at least 12
months after culture conversion.

All patients diagnosed with TB should be offered counseling
and HIV-antibody testing. Previously published guidelines for
counseling and testing and notification of sex partners and those
who share needles with HIV-infected persons should be followed
(44). Particular emphasis should be placed on offering counseling
and HIV-antibody testing to persons with extrapulmonary TB and
persons with TB in the age groups in which most HIV infections
occur (i.e., those ages 25-44 years). Because homelessness may be
a sequela of injecting drug use or HIV disease, information on
behaviors * associated with an increased risk or prevalence of HIV
infection should be routinely sought from homeless persons. If HIV
infection is considered a possibility, counseling and HIV-antibody
testing should be strongly encouraged. Because HIV infection is one
of the strongest known risk factors for the progression of latent
tuberculous infection to TB (39), the presence of HIV infection in
a person with a positive tuberculin skin test (i.e., greater than
or equal to 5 mm induration) is an indication for preventive
therapy regardless of that person's age. The recommended therapy is
isoniazid, 300 mg daily or 15 mg/kg twice weekly for 12 months.
Preventive therapy should be started only after excluding active
pulmonary or extrapulmonary TB.

HIV-infected persons, with or without acquired
immunodeficiency syndrome (AIDS) or other HIV-related disease,
should be given a Mantoux skin test consisting of 5 tuberculin
units of purified protein derivative. Although false-negative
results may result in these persons because of HIV-induced
immunosuppression, positive tuberculin reactions are clinically
meaningful. Persons with clinical AIDS or other HIV-related disease
should receive a chest radiograph and be examined for evidence of
extrapulmonary TB, regardless of the skin test reaction. If
abnormalities are noted, additional diagnostic studies for TB
should be undertaken.

ROLE OF THE HEALTH DEPARTMENT

Health departments must ensure the provision of essential TB
supplies and services for homeless persons regardless of their
ability to pay. Care should be readily accessible to homeless
persons; this often means provision of services at a shelter.
Whenever possible, outreach services should be provided by trained
outreach workers with the same cultural, ethnic, and linguistic
background as the homeless population being served.

Health departments should also ensure that expert TB medical
consultation is available to the clinicians and nurses who provide
health-care services to homeless persons.

State and local health departments should provide TB training
to those who provide health-care services to homeless persons. (CDC
has made training materials available to state health departments
to assist in this training.)

There is a national network of primary health-care programs
for the homeless as a result of the McKinney Homeless Assistance
Act. The 109 community programs supported by the Bureau of Health
Care Delivery and Assistance of the Health Resources and Services
Administration are appropriate partners for local health agencies
in controlling TB among the homeless.

ROLE OF THE U.S. PUBLIC HEALTH SERVICE

The U.S. Public Health Service (PHS) should promote
collaboration between health departments and those who provide
health care to the homeless so that they can plan and implement TB
prevention and control activities. The PHS should require
documentation of such collaboration as part of applications from
states and cities for federally funded grants and cooperative
agreements. In addition, as part of routine site visits, PHS staff
should review state and local TB activities and make
recommendations for more effective collaborative programs.

CONCLUSIONS

Homeless persons suffer disproportionately from a variety of
health problems, including TB. Detecting, treating, and preventing
TB in this special population benefit not only persons who are
homeless, but society at large. The goal of prevention and control
of TB among the homeless is difficult and challenging, but it can
be achieved.

References

CDC. Tuberculosis and human immunodeficiency virus infection:

recommendations of the Advisory Council for the Elimination of
Tuberculosis (ACET). MMWR 1989;38:236-238, 243-250.

2. Knopf SA. Tuberculosis as a cause and result of poverty. JAMA
1914;63(20):1720-5.

3. Marsh K. Tuberculosis among the residents of hostels and
lodging houses in London. Lancet 1957;1:1136-8.

The Advisory Council for the Elimination of Tuberculosis
recognizes that a variety of terms are used and preferred by
different groups to describe race and ethnicity. Racial and ethnic
terms used throughout the document reflect the way data are
collected and reported by official health agencies.

Based on seroprevalence studies, behaviors that place a person at
risk for HIV infection include injecting drug use and male
homosexual contact. Other factors that increase the risk for HIV
infection among adults include having received blood or clotting
factor concentrate between 1978 and 1985 and having had sexual
relations at any time since 1978 with a) a person known to be
infected with HIV or to have AIDS, b) a man who has had sexual
contact with another man, c) prostitutes, d) injecting drug users,
or e) persons born in countries where most transmission of HIV is
thought to occur through heterosexual sexual contact. Risk factors
for HIV infection among infants and children include a) parents,
especially the mother, with HIV infection or any of the adult risk
factors, and b) receipt of blood or clotting factor concentrates
between 1978 and 1985.

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